Large outbreak of urogenital schistosomiasis acquired in Southern Corsica, France: monitoring early signs of endemicization?

OBJECTIVES: Clustered cases of urogenital schistosomiasis were reported in April 2014 among French and German tourists linked to exposure in the Cavu River, Southern Corsica, France, between 2011 and 2013. We set up national surveillance for autochthonous urogenital schistosomiasis to document the largest possible number of cases in order to identify potential sites of transmission and to determine the extent of the outbreak in France and Corsica. METHODS: The early response consisted mostly of prohibiting swimming in the river, performing a nationwide serologic screening of all persons exposed to the river between 2011 and 2013 and treating confirmed cases. Physicians were asked to report all patients with one or more positive antischistosome serologic test. Cases were defined as occurring in a resident of France with serologic evidence of schistosomiasis or schistosome eggs in urine and no history of contact with freshwater in known endemic areas. We documented symptoms as well as place and time of exposure to freshwater for all subjects. To estimate the outbreak size, we modelled the effect of the 2014 nationwide screening on the 2011-2015 time series of serodiagnosed schistosomiasis cases using log-linear autoregression. RESULTS: In 2014, a total of 106 autochthonous cases were reported, including 35 symptomatic infections. All patients had swum in the Cavu during summer 2013. Over 30 000 persons were likely screened for autochthonous schistosomiasis. The model-estimated outbreak size was 338 cases, including 36 serodiagnosed in 2015. CONCLUSIONS: Besides the 2013 outbreak, there is evidence of small-scale transmission in 2015 in Corsica. Early detection and control of recurrences requires raising community and medical awareness.

Community outbreak of group B meningococcal disease in southwest France--December 2008 to September 2009.

Between December 2008 and September 2009, 11 cases of invasive meningococcal disease (IMD) group B were reported in a 20 km diameter area in the Département Landes, France. Two of them presented with purpura fulminans and one of them died. The strain responsible for this community outbreak was of the clonal complex ST-269.The incidence rate for IMD group B was 3 per 100,000 inhabitants in Landes from week 40 in 2008 to week 40 in 2009; it was the highest in France during that period. The number of cases observed was significantly higher than expected, especially in young adults (standardised incidence ratio: 23.5, p<0.001). A nightclub located in the 20 km diameter area was a possible place of transmission and a prophylaxis recommended for the staff members helped in decreasing the transmission. However, several cases notified later suggested that the bacteria circulated during several months through healthy carriers in the community. This situation prompted increased surveillance of IMD in Landes and medical practitioners were asked to remain vigilant because of the possible emergence of new cases within the following months.

[Hemothorax in a 78-year-old woman]. / Hémothorax d'origine iatrogène chez une femme de 78 ans.

We report an atypical presentation of hemothorax. Tamponade and subacute dyspnea occurred secondary to a wound of the right atrium caused by a pacemaker electrode in 78-year-old woman on oral anticoagulants for complete arrhythmia due to atrial fibrillation. This case illustrate an unusual pathophysiological mechanism of hemothorax.

Current practice in Marfan's syndrome and annulo-aortic ectasia: aortic root replacement with a composite graft over a twenty-year period.

BACKGROUND: From October 1973 to December 1995, 251 patients (204 male, 47 female) aged from 10 to 75 years (mean: 46.6 +/- 15) underwent an ascending aortic replacement with a composite graft for: dystrophic aneurysm (AN), 168 cases (66.9%); chronic dissection (CD), 36 cases (14%); and type A acute dissection (AD), 48 cases (19.1%). Fifty-one patients (20.3%) suffered from Marfan's disease (25 AN, 17 AD, 9 CD). Thirty-seven patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 31 patients (12.3%). A mechanical valve was used in 233 patients (92.8%). The classic "Bentall" technique was used in 87 patients (34.6%), the "button" technique in 121 patients (48.2%), the "Cabrol" technique in 26 patients (10.3%) and a "mixed" technique in 17 patients (6.2%). RESULTS: The hospital mortality accounts for 7.2% (18 out of 251) (AN: 4 out of 68, 2.3%, CD: 4 out of 36, 11.1%, AD: 9 out of 48, 18.7%). When emergencies are considered, the hospital mortality is 12 out of 54 (22.2%) versus 6 out of 197 (3%) in elective procedures. The predictors of hospital death were emergency, AD (p < 0.03) and arch replacement (p < 0.02). Mean follow up is 38 +/- 15 months (4-262). The overall long term survival rate is (Kaplan Meïer): 92 +/- 6% at one year, 77.9% +/- 9% at 5 years, 67.7 +/- 12% at 10 years, and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (93 +/- 6%) than in patients with AD (61.6 +/- 17%) (p < 0.01). The late survival rate is also significantly higher after the "button" (93.8 +/- 5%) or Bentall's reimplantation (88.7 +/- 6%, 83.8 +/- 9%, and 76.6 +/- 12%) than after the "Cabrol" procedure (80 +/- 18%, 63 +/- 21% and 58 +/- 35%) at 1, 5, and 8 years, respectively. CONCLUSION: Ascending aortic replacement with a composite graft is a safe procedure, especially when performed electively in patients with dystrophic aneurysm or Marfan's disease. The technique of coronary reimplantation has a significant influence of the long-term results, with the reimplantation of choice being the "button" technique. The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible.

"Classic" repair of congenitally corrected transposition and ventricular septal defect.

BACKGROUND: This study examined the results of "classic" repair of congenitally corrected transposition of the great arteries and ventricular septal defect. METHODS: From 1974 to 1994, 52 patients underwent a classic complete repair of lesions associated with congenitally corrected transposition. They were divided into two groups: ventricular septal defect plus left ventricular outflow tract obstruction (group I, 37 patients) and isolated ventricular septal defect (group II, 15 patients). Tricuspid plasty or replacement was performed primarily in 1 patient of group I (3%) and in 8 patients of group II (53%). RESULTS: The overall operative mortality was 15% (8/52 patients), and the incidence of postoperative atrioventricular block was 27% (14/52 patients). Eight patients died secondarily, 5 of heart failure. Survival rates were 83% +/- 6% at 1 year and 55% +/- 14% at 10 years for group I and 86% +/- 9% at 1 year and 71% +/- 12% at 10 years for group II (not significant). Redo tricuspid plasty or replacement was performed in 12 patients. CONCLUSIONS: Results of classic complete repair of lesions associated with congenitally corrected transposition are not satisfactory in our experience because (1) the operative mortality and the incidences of tricuspid valve replacement and atrioventricular block are high and (2) secondary heart failure is frequent. However, a retrospective review of morphologic findings shows that "anatomic" complete repairs would not have been feasible in 6 of our patients.

Aortic root replacement with a composite graft. Factors influencing immediate and long-term results.

From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean: 44.8 +/- 15) underwent ascending aortic replacement with composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 18.7%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (13.7%). A mechanical valve was used in 193 cases (95%). Since 1986, the ascending aorta has been totally resected and a gelatin-or collagen-coated vascular prosthesis used. The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (P < 0.03) and arch replacement (P < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9 +/- 9% at 5 years, 67.7 +/- 12% at 10 years and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (log. rank: P < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation than after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant influence on the long-term results. The reimplantation of choice is the "button" technique, especially in the presence of a fragile aortic wall (AD). The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible, for instance during redo procedures.

[Surgery FOR annulo-dystrophic disease of the ascending aorta. Apropos of 203 cases]. / Chirurgie de la maladie annulo-dystrophique de l'aorte ascendante. A propos de 203 patients.

From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean 44.8 +/- 15) underwent ascending aortic replacement with a composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 19%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (14%). A mechanical valve was used in 193 cases (95%). The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (p < 0.03) and arch replacement (p < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9% at 5 years, 67.7 +/- 12% at 10 years and 61.3% +/- 15% at 12 years. The 10 years survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (Log.rank: p < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation that after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant on the long-term results.

Effects of calcium concentration, lactobionate content, and sodium/ potassium ratio of preservation solutions on resting left ventricular pressure and postreperfusion function of rabbit heterotopic heart transplants.

BACKGROUND: We tested the hypothesis that the University of Wisconsin solution has a ionic composition (i.e., intracellular, calcium-free, lactobionate-enriched) that may be beneficial for cold heart graft preservation independently from any additives. METHODS: St. Thomas' Hospital and University of Wisconsin solutions were compared with the following: (1) C solution, a simplified University of Wisconsin-like solution (i.e., intracellular, calcium-free, lactobionate-enriched); (2) A solution, an St. Thomas' Hospital-like solution (extracellular, calcium [Ca2+] = 1.2 mmol/L) in which chloride was replaced by lactobionate; (3) B solution, an intracellular, lactobionate-enriched, calcium-containing solution ([Ca2+] = 1.2 mmol/L). Rabbit hearts were transplanted heterotopically in the abdomen of recipient animals either immediately or after 6 hours of storage. Hemodynamic parameters were recorded 60 minutes after unclamping. RESULTS: After a 6-hour storage, University of Wisconsin and C solutions provided better preservation than B and St. Thomas' Hospital solutions: diastolic pressures were lower; developed pressure and rate of pressure rise were higher. C solution was superior to University of Wisconsin solution only for rate of pressure rise. A solution was intermediary. A significant alteration of resting pressure and hemodynamic parameters was generally observed during the 6-hour storage. Nonsignificant changes of developed pressure and rate of pressure rise were only observed in C and B solutions: This is explained by systolic alteration after immediate reimplantation for the B group and good preservation for the C group. Resting pressure was unchanged over a 6-hour storage only for the C group, but this measure was not determined for University of Wisconsin. A correlation exists for various left ventricular volumes between resting pressure and postreperfusion hemodynamic data. Replacement of chloride by lactobionate (A versus St. Thomas' Hospital) may have improved resting and diastolic pressures by other mechanisms than limitation of net water gain during storage.

Reduction of ventilator settings allowed by intravenous oxygenator (IVOX) in ARDS patients.

OBJECTIVE: To evaluate the possibility of reducing ventilator settings to "safe" levels by extrapulmonary gas exchange with IVOX in ARDS patients. DESIGN: Uncontrolled open clinical study. SETTING: Medical Intensive Care Unit of a University Hospital. PATIENTS: 6 patients with ARDS who entered into IVOX phase II clinical trials. INTERVENTIONS: The end-point of this study was to reduce ventilator settings from the initial values, recorded on the day of inclusion, to the following: peak inspiratory pressure < 40 cmH2O, mean airway pressure < 25 cmH2O and tidal volume < 10 ml/kg. Trials to achieve this goal were made on volume-controlled ventilation within the 24 h before and after IVOX insertion. Comparison of the results achieved during these trials used Wilcoxon test. RESULTS: Before IVOX implantation reduction of ventilator settings was not possible in the 6 patients, despite a non-significant increase in PaO2/FIO2 was achieved. IVOX permitted significant decrease in PaCO2 (from 60.5 +/- 15 to 52 +/- 11 mmHg; p = 0.02) before any modification of the ventilatory mode. After IVOX insertion, a significant decrease of the ventilator settings was performed: peak and mean airway pressures dropped from 44 +/- 10 to 36.8 +/- 6.7; p = 0.02 and from 26.3 +/- 5.6 to 22.5 +/- 3.9 cmH2O; p = 0.02, respectively. Concommitantly, PaCO2 remained unchanged and PaO2/FIO2 increased significantly from 93 +/- 28 to 117 +/- 52; p = 0.04. The interruption of oxygen flow on IVOX was associated with a slight decrease of the oxygen variables. Tolerance of IVOX was satisfactory. However, a significant decrease both in cardiac index and in pulmonary wedge pressures (from 4.5 +/- 1.2 to 3.4 +/- 9; p = 0.03 and from 16 +/- 5 to 11 +/- 2; p = 0.04, respectively) was observed. CONCLUSION: Gas exchange achieved by IVOX allowed reduction of ventilator settings in 6 ARDS patients in whom previous attempts have failed. CO2 removal by the device, may explain these results. Efficacy of IVOX on arterial oxygenation was uncertain.

Permissive hypercapnia and intravascular oxygenator in the treatment of patients with ARDS.

This open clinical study was aimed at testing the hypothesis that an intravascular oxygenator (IVOX) may help to perform permissive hypoventilation in 10 patients with severe ARDS. After initial evaluation, we tried to reduce ventilator settings before and after IVOX implantation. Before IVOX, poor clinical tolerance and worsening oxygenation did not allow for a significant decrease in ventilator settings. With IVOX, peak inspiratory pressure (PIP) was reduced from 47 to 39 cm H2O (p = 0.005) and minute ventilation from 13 +/- 3.5 to 11 +/- 3 L/min. CO2 removal by IVOX allowed a significant decrease in PaCO2 from 66 +/- 15 to 59 +/- 13 mm Hg. Improvement of oxygenation with IVOX was not significant. Furthermore, interruption of oxygen flow through IVOX did not change oxygenation variables. Tolerance of the IVOX device was good, but insertion of the device was followed by a significant decrease in both cardiac index and pulmonary wedge pressure. In conclusion, IVOX improves tolerance of hypoventilation by limiting hypercapnia in ARDS patients. These preliminary results must be confirmed by a randomized controlled study.

Aortic dissection. Prevalence, cause, and results of late reoperations.

From January 1977 to September 1992, 143 patients underwent an emergency operation for type A acute aortic dissection. Because of the location of the intimal tear, the replacement of the ascending aorta was extended to the transverse arch in 42 patients (29.3%). One hundred ten patients (78%) survived the operation. During the same period, 32 patients had to be reoperated on once (n = 24) twice (n = 6), or three times (n = 2) for a total of 42 reoperations. Nineteen patients had had the initial repair in our institution, and 13 had been operated on elsewhere. Reoperation was indicated for aortic valve disease (n = 4), recurring dissection (n = 7) threatening aneurysmal evolution of a persisting dissection (n = 28), or false aneurysm (n = 3). The redo procedure involved the aortic root and/or ascending aorta in 15 cases (group I), the transverse arch alone in 7 cases (group II), the transverse arch and the descending aorta or the descending aorta alone in 10 cases (group III), or the thoracoabdominal aorta in 10 cases (group IV). The risk factors for reoperation have been analyzed in the 110 survivors initially operated on in our institution. Seven of 18 patients with Marfan's syndrome (38.8%) versus 12 of 92 without Marfan's syndrome (13%) were reoperated on (p = 0.023). None of the 30 patients surviving arch replacement at initial repair required a reoperation, versus 19 of 80 (23.7%) patients surviving a replacement limited to the ascending aorta (p = 0.013). The overall mortality rate of reoperation was 21.8% (7/32) with a risk of 16.6% (7/42) at each procedure (group I, 13.3%; group II, 0%; group III, 20%; group IV, 30%). Hospital mortality was influenced by emergency operation (5/10) (p < 0.005) and thoracoabdominal replacement (3/10) (p < 0.035). The late survivals after reoperation are 65.1% +/- 17.6% at 1 year and 55% +/- 19.63% at 5 years (Kaplan-Meier, confidence interval 95%). The late survivals, after the initial repair, of the patients undergoing reoperation are 89.6% +/- 11.0%, 79.3% +/- 14.7%, 53.9% +/- 18.1%, and 35.9% +/- 21.8% at 1, 5, 10, and 12 years, respectively. In conclusion, aortic dissection is an evolving process that may require one or several reoperations after the initial repair. At initial emergency operation, the resection of the entry site, when located on or extending to the transverse arch, has reduced the risk of reoperation, in our experience. Elective reoperation must be considered before the occurrence of complications, especially in patients with Marfan's syndrome.(ABSTRACT TRUNCATED AT 400 WORDS)

Experimental evaluation of Celsior, a new heart preservation solution.

An original heart preservation solution (Celsior) has been developed, the formulation of which has been designed to fulfil two major objectives: (1) to combine the general principles of hypothermic organ preservation with those specific for the myocardium, and (2) to offer the possibility of being used not only as a storage medium but also as a perfusion fluid during initial donor heart arrest, poststorage graft reimplantation and early reperfusion. The major principles addressed by the Celsior formulation include (1) prevention of cell swelling (by mannitol and lactobionate), (2) prevention of by the Celsior formulation include (1) prevention of cell swelling (by mannitol and lactobionate), (2) prevention of oxygen-derived free radical injury (by reduced glutathione, histidine and mannitol), and (3) prevention of contracture by enhancement of energy production (glutamate) and limitation of calcium overload (high magnesium content, slight degree of acidosis). Two experimental preparations were used: The isolated isovolumic buffer-perfused rat heart model and the heterotopic rabbit heart transplantation model. In isolated heart experiments, hearts were arrested with and stored in Celsior for 5 h at 4 degrees C and subsequently reperfused for 1 h. A similar protocol was used in the transplantation experiments except that the total ischemic time was approximately 1 1/2 h longer (corresponding to 6 h of storage followed by the 25 additional minutes of cold ischemia required for graft implantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperacute xenograft rejection in the swine-to-human donor-recipient combination. In vitro analysis of complement activation.

Complement activation is central to the rejection of discordant xenografts. In order to assess the respective roles of direct and alternative pathways, an in vitro model of hyperacute rejection in the swine-to-human donor-recipient combination was designed, using a complement-dependent cytotoxicity test with swine endothelial cells in culture as targets, and fresh human serum as the source of xenogeneic antibodies and complement. The cytotoxic activity of the sera was evaluated by a colorimetric assay using (3-[4,5-dimethyldiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT). Pure human serum lysed 58 +/- 5% of swine endothelial cells. Selective inhibition of the direct pathway by adding EGTA to the serum reduced cytolysis to 51 +/- 2% (P < 0.01 versus normal serum). Similarly, when using C1q-deficient human sera, only 37 +/- 7% of swine endothelial cells were killed (P < 0.001 versus normal serum). When the alternative pathway was selectively inhibited by heating for 20 min at 50 degrees C, the lytic activity of human serum dropped to 42 +/- 5% (P < 0.001 versus normal serum). Factor B-deficient human serum could only lyse 42 +/- 10% of porcine endothelial cells (P < 0.001 versus normal serum). Syngeneic normal swine serum and heat-inactivated serum were not cytotoxic. Mixing serum with deficient direct pathway and serum with deficient alternative pathway restored the cytotoxicity to normal levels. Similarly, the cytotoxic activity of deficient serum supplemented with purified C1q or factor B at physiological concentrations reached that of normal human serum. In this model of in vitro hyperacute rejection, both pathways of complement activation are involved, suggesting that regimens designed to inhibit hyperacute rejection of swine xenografts into humans should take into account the dual activation of complement in this donor-recipient combination.

[Pulmonary valve atresia with intact interventricular septum. Mid-term results of the surgical treatment. Apropos of 45 cases]. / Atrésie pulmonaire à septum interventriculaire intact. Résultats à moyen terme du traitement chirurgical. A propos de 45 observations.

Between 1980 and 1991, 45 patients with pulmonary atresia with intact interventricular septum (38 cases) or critical pulmonary stenosis (7 cases), underwent surgery. The right ventricle was tripartite in 23 children, bipartite in 12 and unipartite in 10. Sinusoid vessels were present in 20 cases. They reinjected a native coronary trunk in 10 cases (major sinusoids). During the initial operation performed in the neonatal period in 41 cases and later in 4 cases, 26 children had an isolated systemic-pulmonary shunt (3 deaths) and 19 had connection of the right ventricle and pulmonary artery (6 deaths). Perioperative mortality was 20% (9/45). Global actuarial survival at 5 years was 47%. Of the 22 patients referred later for univentricular repair, 8 (36%) died (6 perioperative and 2 sudden deaths). The actuarial survival for this group was 49% at 4 years. Of the 23 patients referred for biventricular repair, 11 (47%) died (9 perioperative and 2 sudden deaths) and 2 attained complete cure status. The actuarial survival is 43% at 4 years in this group. Children with intermediate forms (type II or tricuspid less than 8 mm) were orientated to univentricular repair, partly due to the high incidence of major sinusoids. None of the children with major sinusoids survived to over 3 years of age. When the anatomic form is favorable, the present strategy is to perform transpulmonary valvotomy under cardiopulmonary bypass associated with the implantation of a Gore-Tex tube between the innominate artery and right pulmonary artery during the neonatal period. The risk of secondary pulmonary regurgitation would seem to be less than the immediate risk of low pulmonary flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch.

Profound hypothermia associated with circulatory arrest is the commonest method of cerebral protection during operations on the aortic arch. This technique allows a limited time to perform the aortic repair, however. It also necessitates prolonged cardiopulmonary bypass to rewarm the patient. This may be the cause of coagulation disorders or infection. Selective perfusion of the carotid arteries can also be used. When the perfusion is derived from the main arterial line, however, the repair of the aorta requires that the vessel be crossclamped, and cannot be performed in an "open, bloodless" manner. To avoid the disadvantages of both techniques, we have developed a new technique of cerebral protection. After a regular cardiopulmonary bypass has been established, the carotid arteries are cannulated and perfused with blood cooled at 6 degrees to 12 degrees C, through a separate heat exchanger, while the core temperature is maintained at moderate hypothermia (25 degrees to 28 degrees C, rectal). To perform the "open" distal repair, the cardiopulmonary bypass is discontinued while the carotid perfusion is maintained (250 to 350 ml/min). When the distal repair is completed, cardiopulmonary bypass is resumed and the carotid perfusion is discontinued. Between 1984 and June 1989, 54 patients (mean age 55 years) were operated on with this method (45 elective operations, 9 emergency procedures). Mean duration of cardiopulmonary bypass was 121 minutes (65 to 248), and mean duration of circulatory arrest was 22 minutes (10 to 51). The electroencephalogram, routinely recorded, showed return of the cerebral activity after a mean time of 12 minutes and normal activity after a mean time of 66 minutes. There was no intraoperative death. Hospital mortality rate was 13% (7/54). One death was related to neurologic disorders. All patients but one awakened normally within 8 hours after operation. Two patients (4.3%) experienced a transient neurologic episode (lateral hemianopia) 9 and 11 days postoperatively. There was no hemorrhagic complication (24-hour average blood loss: 840 +/- 540 ml). In our experience the technique of "cold cerebroplegia" has been demonstrated to provide excellent cerebral protection. It requires no prolonged cardiopulmonary bypass and does not limit the time necessary to perform the aortic repair. It may be considered as a safe alternative to profound hypothermia associated with circulatory arrest.